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  ========================LICENSE_START=================================
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  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
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<html xmlns:wicket="http://wicket.apache.org">
<wicket:extend>
    <div class="row-fluid">
        <div class="span12">
            <h1 class="pageTitle">
                Huisarts gegevens
            </h1>
        </div>
    </div>
    <div class="row-fluid form-horizontal">
        <fieldset>
            <div wicket:id="paspoortContainer">

                <wicket:container wicket:id="paspoort"></wicket:container>
            </div>

            <form wicket:id="form">
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>1. AGB-code en NAW gegevens</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">AGB-code </label>
                                <div class="controls">
                                    <label class="text" wicket:id="agbcode"></label>
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Gebruikersnaam </label>
                                <div class="controls">
                                    <label class="text" wicket:id="gebruikersnaamHuisartsenPortaal"></label>
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">E-mail</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="email">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Extra e-mail(s)</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="extraEmails">
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <button type="button" class="btn btn-default" wicket:id="wachtwoordreset">Reset
                                    wachtwoord
                                </button>
                            </div>
                        </div>
                    </div>
                    <hr/>
                    <div class="row-fluid">
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Aanhef</label>
                                <div class="controls">
                                    <select wicket:id="organisatieMedewerkers[0].medewerker.aanhef">
                                        <option selected disabled>- Maak een keuze -</option>
                                        <option>Dhr.</option>
                                        <option>Mevr.</option>
                                    </select>
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Achternaam</label>
                                <div class="controls">
                                    <input class="input-large" type="text"
                                           wicket:id="organisatieMedewerkers[0].medewerker.achternaam">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Tussenvoegsel</label>
                                <div class="controls">
                                    <input class="input-mini" type="text"
                                           wicket:id="organisatieMedewerkers[0].medewerker.tussenvoegsel">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Voorletter(s)</label>
                                <div class="controls">
                                    <input class="input-mini" type="text"
                                           wicket:id="organisatieMedewerkers[0].medewerker.voorletters">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Telefoonnummer</label>
                                <div class="controls">
                                    <input class="input-large" type="text" wicket:id="telefoon">
                                </div>
                            </div>
                        </div>
                        <div class="span6">
                            <div class="control-group">
                                <label class="control-label">Straatnaam</label>
                                <div class="controls">
                                    <input class="input-large" type="text" value="Straatnaam"
                                           wicket:id="postadres.straat">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Huisnummer + toevoeging</label>
                                <div class="controls">
                                    <input class="input-small" type="text" value="123"
                                           wicket:id="postadres.huisnummer"> <input
                                        class="input-mini" type="text" value="A"
                                        wicket:id="postadres.huisnummerToevoeging">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Postcode</label>
                                <div class="controls">
                                    <input class="input-mini" type="text" value="1234 AB"
                                           wicket:id="postadres.postcode">
                                </div>
                            </div>
                            <div class="control-group">
                                <label class="control-label">Plaats</label>
                                <div class="controls">
                                    <select class="input-large"
                                            wicket:id="postadres.woonplaats"></select>
                                </div>
                            </div>
                        </div>
                    </div>
                </fieldset>
                <fieldset>
                    <div class="row-fluid">
                        <div class="span12">
                            <legend>2. Locaties</legend>
                        </div>
                    </div>
                    <div class="row-fluid">
                        <div class="span12" wicket:id="locatiesContainer">
                            <div wicket:id="locaties"></div>
                        </div>
                    </div>
                </fieldset>
                <div class="row-fluid">
                    <div class="span12" wicket:id="buttonContainer">
                        <div class="form-actions btn-bottom">
                            <button class="btn" wicket:id="inactiveren">
                                <i class="icon-minus-sign"></i> <span>Inactiveren</span>
                            </button>
                            <button class="btn btn-primary" wicket:id="opslaan">Opslaan</button>
                        </div>
                    </div>
                </div>
            </form>
        </fieldset>
    </div>
    <div wicket:id="dialog"></div>
</wicket:extend>
</html>
